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A DOCTOR'S DILEMMA
Dr Margot Nelson-Owen
British Medical Journal, Volume 315, August 30, 1997
ATTENTION DRUG ABUSERS:
As of [insert date] this practice will no longer be prescribing any potentially addictive drugs to patients with a drug dependency problem.
Detoxification from addictive drugs will be our normal practice.
Methadone will be prescribed as a single dose and will be marked "observe taking".
SUGGESTED DISPLAY POSTER FOR GP PRACTICES
It is difficult to criticise the working practices of other doctors. You leave medical school with a sense of belonging to a family of time honoured physicians who have given their lives to healing the sick and treating the needy. The Hippocratic oath tells us to be loyal to the profession of medicine and just and generous to its members. You learn about the fundamentals of pharmaceutical practice – first do no harm. It is this last statement with which my conscience is struggling, and which is responsible for the dilemma I face.
There is a real problem out there – and it is not what it seems. I used to think – those junkies, they are no-hopers. How can you help people who don't care, or who don't want to help themselves? The reality is different. General practitioners and community drug team doctors have a lot to answer for.
I see many 17-year-olds who come into prison on genuine repeat prescriptions of all sorts of addictive drugs such as diazepam, temazepam, methadone, dihydrocodeine – this can't be right. Why are these children being prescribed such potentially destructive drugs? Who is failing these children? Is it the single parent? Is it the teacher who can no longer cope? Is it the social services? Is it the general practitioner who has no time because of a busy surgery?
The child is crying out for help and gets none. The general practitioners face an impossible situation. Where do they start? Unable to offer any real help and guidance, they pull out a prescription pad and start the child on the slippery road of mind-altering, thought blocking drugs like diazepam. They will take away the pain, the sense of failure now, but for how long? They are addictive drugs, and instead of helping they just create future problems.
Instead of finding someone who really cares, the 17-year-old is betrayed yet again. He or she needs more drugs to continue "to exist" and starts buying them on the streets. Petty crimes are committed to fund the ever-increasing habit. Soon harder drugs are tried: a bit of amphetamine. The next step...heroin.
By now the teenagers know all the tricks. They tell the well intentioned practitioner or doctor from the community drug team that they have been "jacking up" six or seven times a day. With any luck the doctors will not ask to see the bruised arms or any evidence of opiate withdrawal before handing out a prescription for methadone. This is then collected from the pharmacist and sold on to buy the heroin.
Yes I have become sceptical and I do not always believe everything my patients tell me. This was difficult for me initially. You go through medical school being told to listen to your patients and believe what they tell you.
Drug abusers who need a "fix" are abusive, irrational, deceptive, manipulative and tell you the most amazing stories. I was "conned" many times at the beginning, but I'm getting harder to "con" now. They will go to the most amazing lengths to get what they want. The need help. Continuing their habit is not really helping them. They need to feel that life is worth living.
I am sure that doctors prescribe methadone, opiate analgesics and benzodiazepines in good faith. We need to change the current prescribing practice. Many think of us as legalised pushers and I for one am appalled at this association.
In my present job as a prison medical officer I have been able to spend a lot of time with drug misusers. Initially I was given a rough time. "Doc, you're making my life hell"; "I need more Doc"; "Doc I'm cracking up". But with support, encouragement and hard work they kick their habit. Many would give me a hug and say, "Nice one Doc"; "You put me through hell Doc, but thank you".
If you think I have a bee in my bonnet about drugs you would be right. I see so many young lives being ruined by drug misuse. In the past six months we have detoxified 85 inmates addicted to benzodiazepines and heroin. Many of them have gone straight back to their general practitioners on release and have been put back on these life-destroying drugs. What is so worrying is that their tolerance to these drugs is so much lower now and taking their former doses could kill them.
It is all too easy for patients to drift into a way of life which relies on taking a drug to get through the day. Doctors should make their patients aware of the problems of dependence and not collaborate with it. I ask all doctors with drug misusers on their lists to stop and think what they are doing. Are you one of the 'legalised pushers'? I suggest that practices should display a poster in the surgery (see above).
Dr Margot Nelson-Owen
Prison Medical Officer, Cardiff
BMJ, Vol 315, August 30, 1997
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